Dr. Stephen Kinsella:

On the question of whether we are top-heavy with management within the HSE, my role was not to look at the HSE but to look at everybody else and come back. I am hesitant to criticise the HSE because everyone does. My sense is that if 25% of staff are doing management, administration and support it feels like a lot, but one has to look at where they began and where we are now. I am not trying to evade the Chairman's question but I would be much more interested in the question of what it would look like in ten years' time - would there still be a 25% ratio or would it be reduced to 15% by using better technology to do some of the work and what does that mean for those administrative staff? When one considers the ratio of management to administrative staff within the HSE versus comparator countries, the percentages do not look wildly out of kilter. However, those data have to be taken with a pinch of salt because there may be nurses who perform lots of administrative work and there may be support staff who do much of the front-line work, so we are not 100% sure.

With regard to talent management and rewards within the system, the public sector is, unfortunately, not replete with massive amounts of rewards within the system. I cannot imagine what a bonus culture would look like in universities, for example. I would love one, if the politicians want to do one - that would be great. I believe that our public sector and public structures are still within a very early-20th-century mode in which one gets a job for life, stays there and moves up in terms of seniority. I do not see any evidence that it is different in other parts of the system. My own experience is mostly within the higher education system, but I do not see any evidence that it is different.

Deputy Barry asked about work planned around the national strategies, such as the maternity and cancer strategies. That can be done, but if we do that we will not get around to the major ones for quite some time. I believe there are some 30 different clinical care pathways. If we worked on one plan at a time and each one took three years, that would be 90 years. Even this long-term committee does not quite hold to that. I believe that we need to do one overarching plan and maybe work on specific modules at the same time. It is important to have a workforce planning unit - that is, a group of 10 or 15 people whose sole purpose is to gather all the data. It should not be done separately by Solas, the HSE and the Department of Health. The group would gather the data and would fit it into the e-health strategy and all the rest of the system. In being enabled to do so, the group would build up a competence so it can determine, for example, a module on midwives. We saw this in Scotland, where a workforce planning module was prepared specifically for midwives. This has happened in other places also, where having people on the ground with the data means that further investigations can happen in a particular dimension, as policy makers require. For example, we know that diabetes levels are going to increase massively, so we may need more diabetes nurses - who knows? It will be a case of planning for that. We know it is going to get worse: the clinicians are telling us that we will have a problem into the future. Autism care requirements may increase. Care for people with different developmental disorders and those with mental health care requirements will increase. We will need to do a workforce plan for that. It would all be done in one place and it would not be aligned to a particular strategy whose work, when the strategy runs it course, might never feed back into anything else. That would be one of my ideas - one resource putting all the data together.

With regard to the section 30 queries by Deputy Daly, that is why one needs to have a governance structure at the level of the HSE.

Even the Department of Health finds it difficult to get data from some section 37 and 38 organisations. The Government will need to change the law in order to have them comply as efficiently as possible, as if they were fully public hospitals. Again, it is interesting; it comes back to our history in that voluntary care has typically been provided in the absence of the State providing it and so what one has is a half-way house whereby one has charities doing the State's work that are poorly regulated. People are set up to do a job, whose vocation in life is to help homeless people or people whose children are dying of cancer, for example, and one is saying to them that they must also fill out a risk register and the skill-sets are just not there.

I do not have the answer but a good question for me to pose to the committee is whether we have too many charities. That is a question this committee could answer. What are the consequences if the answer is "Yes"? If the answer is "Yes" then this committee must recommend that some of those charities get amalgamated, go away or become regulated out of existence. That is a big question. Do we have too many hospitals? That is another big question. Do we have too few? This is why we elect Deputies. They must answer those questions. I wish members good luck in answering them.

In terms of the information, the law must change. Some of the organisations are just private companies, effectively, with a board of management and the CEO is subsumed into the board and the board might decide it is not giving the information. The HSE has made lots of changes in order to get the information on a timely basis and it is starting to get to the nub of some of the issues, but I strongly suggest that with thousands of charities we have not seen the end of this.

A good question is whether we adjust the system we have or strategise for the system that we want. I strongly urge the second option. I would argue that one should set the strategy for the system one wants and one should build funding on a multi-annual basis in order to get there. The best example of that is the city of Copenhagen. It was decided to plan the city using the finger model and to develop in a certain direction along one finger for five years and then go back and develop another finger and then another one. The intention was to connect up the fingers using public transport. Anyone who has been there will know it is a very nice city. They did not plan for the city they had, they planned for the city they would have and then money was put in as it became available. When the money was not available no building took place, but over a 30-year period they produced a beautiful city. One could do the same with the health system. One would do it by simply sticking to a plan. That is why it is called strategic health workforce planning. It is strategic because the Government sets the strategy. It is interesting to see where the strategy is set but my hope is that it would be at Cabinet level and committee level.

In reply to the question of whether ratios should be our best starting point, the answer is "Yes" but what one will find is that the ratios are different by country depending on their institutional structure, so one must control for that and it is quite difficult to achieve. I have seen many of studies that tried to do this. Eventually, what they end up doing is focusing on doctors, nurses and physiotherapist and then they give up because it is very difficult to get comparable data. Reference was made earlier, for example, to nurses and nurses aides but they do not have those comparable distinctions in other countries which means one cannot compare them directly and it becomes a little difficult. That said, we could do that as our starting point. To my knowledge it has not been done but I am open to correction. It could be done as part of the work of the committee. I imagine the HSE would be the first ones to do it.

In terms of allocation of resources and staff ratios, one should follow the other. The question is what is the appropriate staff ratio. There must be dialogue with the people who do the service. If one does not, one will impose a system where there are too many doctors and not enough nurses or one will forget something. I believe in listening to the people who do the work. That is probably the best way to do it, and that is informed by best practice.